Lymphogranuloma venereum (LGV) in Europe emerged in 2003 affecting mostly MSM. Rectal primary LGV causing proctitis has been by far de most common clinical manifestation. In Barcelona, with a cumulative number of around 200 cases up to 2012, some cases have appeared with extrarectal manifestations since 2008. We report two cases in MSM with genital primary LGV mimicking primary syphilis.

Case 1. A 29-year-old HIV-positive man presented with a genital chancre and inguinal lymphadenopathy of 10 days’ duration. He reported 5 casual partners the last 3 months. Although dark-field exam was negative the patient was treated with benzathine penicillin G 2.4 million units. He was seen 4 days later without improvement, with buboes and genital edoema. A swab from the ulcer was positive for LGV and negative for syphilis and chancroid by PCR. A diagnosis of bubonulus was made, and the patient started doxycycline 100 mg/12 h for 21 days. He improved persisting a small residual soft mass on the shaft of the penis.

Case 2. A 37-year-old HIV-negative man presented with a genital ulcer and lymphadenopathy of 2 days’ duration. He had multiple unprotected casual partners in sex parties 3 days before. Three consecutive dark-field exams were negative. Five days later the ulcer persisted like a chancre and inguinal buboes were more evident. LGV was detected from the ulcer while syphilis and herpes were negative by PCR. The clinical manifestations resolved quickly after completion of treatment with doxycycline as above.

Cases with non-rectal lesions would be expected as LGV spreads. When present, the most common presentation of the primary lesion in the genitalia is a nonindurated herpetiform evanescent ulcer. Clinicians must be vigilant to the evolving faces of LGV, be prepared to recognise the full manifestations of this disease and consider LGV in the differential diagnosis of genital chancre.